Double-bundle anterior cruciate ligament reconstruction technique has advantages in chondroprotection and knee laxity control compared with single-bundle technique : A long-term follow-up with a minimum of 12 years

Transphyseal ACL reconstruction and tenodesis in skeletally immature patients demonstrates encouraging clinical scores, without growth disturbance, excessive laxity or re-injury

Purpose

Paediatric patients demonstrate high re-rupture rates after anterior cruciate ligament reconstruction (ACLR), with numerous surgical techniques proposed to deal with this challenging cohort. This study investigated the early clinical outcomes, complications, return to sport (RTS) and re-rupture rates up until 2-years post-surgery in paediatric patients presenting with open growth plates undergoing transphyseal ACLR that was combined with an extra-articular tenodesis (LET).

Methods

Between October 2017 and September 2020, 20 skeletally immature patients were consecutively recruited and underwent transphyseal ACLR and LET. Patient reported outcome measures (PROMs), KT-1000 laxity, knee range of motion (ROM), maximal isokinetic knee torque and a 3-hop battery were assessed at 6-, 12- and 24-months. Limb Symmetry Indices (LSIs), RTS rates, complications, re-ruptures and re-operations were reviewed.

Results

All PROMs improved (p < 0.05). No change (p = 0.903) in laxity between limbs was seen, while 18 patients (90%) demonstrated normal (<3 mm) or near normal (3-5 mm) laxity differences. Peak knee flexion ROM improved over time (p = 0.028), while LSIs for knee extensor strength (p < 0.001), the single (p = 0.002) and triple crossover (p = 0.038) hop tests improved. At 24 months, 18 patients (90%) were participating in their pre-injury pivoting sport activities. No complications, growth disturbances, re-injuries or subsequent surgeries were observed.

Conclusions

Transphyseal ACLR combined with LET, undertaken in skeletally immature paediatric patients, demonstrated high scoring PROMs, physical performance and RTS overall, without evidence of growth disturbance or excessive graft laxity. No re-injuries have been observed at this time with ongoing review required in this high-risk cohort.

Double-bundle anterior cruciate ligament reconstruction resulted in better International Knee Documentation Committee objective grading at fifteen year follow-up compared to single-bundle reconstruction

PURPOSE

The aim of this prospective randomized study was to evaluate whether the use of the anatomic double-bundle (DB) method for anterior cruciate ligament (ACL) reconstruction results in better clinical outcomes and a lower incidence of graft failure compared with the anatomic single-bundle (SB) method. The hypothesis was that DB ACL reconstruction would result in a lower incidence of graft failure.

METHODS

Patients were randomly assigned to either the SB group (n = 78) or the DB group (n = 75). Evaluation included clinical testing, subjective assessments, functional testing, and International Knee Documentation Committee (IKDC) objective grading. Surgical techniques were anatomic, and the rehabilitation protocol was standardized.

RESULTS

At 15-year follow-up, information was available on 100 patients (65%), of whom 55 (36%) were accepted in the final statistical analysis. There were almost three times as many graft failures in the SB group, but the result wasn´t statistically significant. Subjective assessments, knee stability (KT -1000 and pivot shift), range of motion (ROM), and functional one leg hop test showed no statistically significant differences between the groups. However, DB ACL reconstruction resulted in better International Knee Documentation Committee objective grading (P < 0.001).

CONCLUSION

At the 15-year follow-up, double-bundle surgery resulted in significantly better International Knee Documentation Committee objective grading compared to single-bundle surgery.

Effects of higher femoral tunnels on clinical outcomes, MRI, and second-look findings in double-bundle anterior cruciate ligament reconstruction with a minimal 5-year follow-up

BACKGROUND

To perform anatomical anterior cruciate ligament reconstruction (ACLR), tunnels should be placed relatively higher in the femoral anterior cruciate ligament (ACL) footprint based on the findings of direct and indirect femoral insertion. But the clinical results of higher femoral tunnels (HFT) in double-bundle ACLR (DB-ACLR) remain unclear. The purpose was to investigate the clinical results of HFT and lower femoral tunnels (LFT) in DB-ACLR.

METHODS

From September 2014 to February 2016, 83 patients who underwent DB-ACLR and met the inclusion and exclusion criteria were divided into HFT-ACLR (group 1, n = 37) and LFT-ACLR (group 2, n = 46) according to the position of femoral tunnels. Preoperatively and at the final follow-up, clinical scores were evaluated with International Knee Documentation Committee (IKDC), Tegner activity, and Lysholm score. The stability of the knee was evaluated with KT-2000, Lachman test, and pivot-shift test. Cartilage degeneration grades of the International Cartilage Repair Society (ICRS) were evaluated on magnetic resonance imaging (MRI). Graft tension, continuity, and synovialization were evaluated by second-look arthroscopy. Return-to-sports was assessed at the final follow-up.

RESULTS

Significantly better improvement were found for KT-2000, Lachman test, and pivot-shift test postoperatively in group 1 ( P >0.05). Posterolateral bundles (PL) showed significantly better results in second-look arthroscopy regarding graft tension, continuity, and synovialization ( P <0.05), but not in anteromedial bundles in group 1. At the final follow-up, cartilage worsening was observed in groups 1 and 2, but it did not reach a stastistically significant difference ( P >0.05). No statistically significant differences were found in IKDC subjective score, Tegner activity, and Lysholm score between the two groups. Higher return-to-sports rate was found in group 1 with 86.8% (32/37) vs. 65.2% (30/46) in group 2 ( P = 0.027).

CONCLUSION

The HFT-ACLR group showed better stability results, better PL, and higher return-to-sports rate compared to the LFT-ACLR group.

Double-bundle anterior cruciate ligament reconstruction in patients aged 60 years and older

Background

This study aimed to examine the clinical outcomes of double-bundle (DB) anterior cruciate ligament (ACL) reconstruction in patients aged ≥60 years.

Methods

Anatomical DB-ACL reconstruction using hamstring tendon autografts was performed in 13 patients aged ≥60 years at our institution between June 2012 and May 2018. The patients included seven men and six women, and the mean age at surgery was 65.0 years (range, 60-73 years). The mean time from injury to surgery was 80.5 months (range, 1-480 months), and the mean follow-up time was 26.2 months (range, 24-42 months). All patients were assessed based on physical examination findings, clinical scores, Kellgren-Lawrence grades preoperatively and at the final postoperative follow-up, intraoperative meniscal or chondral lesions, and perioperative complications. Status of returning to sports for all patients was assessed at the final follow-up.

Results

The mean side-to-side differences by arthrometer improved from 4.3 mm (range, 2-8 mm) to 0.9 mm (range, 0-2 mm), and the positive pivot-shift test decreased from 100% to 8%. The mean extensor muscle strength was 93.3% (range, 74-116%) postoperatively. The mean Lysholm score improved from 71.1 (range, 27-85) to 95.2 (range, 89-100). Ten of the 13 patients (77%) returned to their pre-injury level of sports performance, and one patient (8%) returned to sports with less intensity. Intraoperatively, meniscal tears were observed in 10 patients (77%), and chondral lesions >grade 2 were observed in 11 (85%). One patient developed perioperative complications. At the final follow-up, the Kellgren-Lawrence grade worsened in only one patient. No re-injury or infection was observed, and revision surgery was not required for any patients.

Conclusions

Anatomical DB-ACL reconstruction could provide satisfactory clinical outcomes and knee function restoration in patients aged ≥60 years.

Level of evidence

A retrospective study, case series (IV).

Review of Cha et al. (2005) on "Arthroscopic Double Bundle Anterior Cruciate Ligament Reconstruction: An Anatomical Approach"

This classic discusses the original publication 'Arthroscopic double-bundle anterior cruciate ligament reconstruction (ACL): An anatomical approach', the first detailed description of the surgical technique popularised by Dr Freddie Fu. The technique, in which the anteromedial and posterolateral bundles of the ACL are reconstructed individually using two grafts with independent bone tunnels, was designed to more closely recreate the function of the native ACL by more closely reproducing the functional anatomy. This reconstruction was biomechanically superior to single-bundle reconstruction, particularly with regards to rotational control, leading to great interest from ACL surgeons around the world. Clinical superiority was more difficult to demonstrate; however, and the technical difficulty of the procedure has limited its use. Nevertheless, the pursuit of improved patient outcomes through attention to functional anatomical detail continues. 'Recreating the functional anatomy of the intact ACL remains the cornerstone of ACL reconstruction'.

Loaded open-kinetic-chain exercises stretch the anterior cruciate ligament more than closed-kinetic-chain exercises: In-vivo assessment of anterior cruciate ligament length change

BACKGROUND

Usage of open-kinetic-chain (OKC) or closed-kinetic-chain (CKC) exercises during rehabilitation planning after anterior cruciate ligament (ACL) reconstruction has been debated for decades. However, the ACL elongation pattern during different rehabilitation exercises at different loadings remains unclear.

OBJECTIVES

This study aimed to determine the effects of OKC and CKC exercises on the length of ACL anteromedial bundle (AMB) and posterolateral bundle (PLB) to provide biomechanical support for making rehabilitation schedules.

DESIGN

Laboratory Descriptive Study.

METHOD

Eighteen healthy volunteers were asked to perform two OKC motions, including non-weight-bearing and 10 kg loaded seated knee extension (OKC-0, OKC-10), as well as two CKC motions, including box squat (BS) and deep single-legged lunge (Lunge). Techniques of 2D-to-3D image registration and 3D ligament simulation were used to quantify length changes of ACL.

RESULTS

The motion which led to the least and most ACL elongation were OKC-0 and OKC-10, respectively. The AMB and PLB were significantly longer in OKC-10 than those in OKC-0 during 0-60° and 0-55° of knee flexion (p < 0.01). Compared with reference length, the AMB and PLB were stretched during 0-30° and 0-10° respectively during OKC-10. During CKC exercises, the AMB and PLB were also stretched from 0 to 25°and 0-5°, respectively. Additionally, no significant difference was found in the length change of ACL bundles between BS and lunge.

CONCLUSIONS

OKC-0 may be safe for the rehabilitation program after ACL reconstruction, and loaded exercises shall be applied when restricted with >30° in early-stage rehabilitation.

Anterior Cruciate Ligament Reconstruction with Autologous Hamstring Single- versus Double-Bundle Graft: A Prospective Study with 10-Year Follow-up

The purpose of the present study was to compare the clinical and subjective outcomes of anterior cruciate ligament (ACL) reconstruction using an autologous hamstring double bundle (DB) with a single bundle (SB) after a 10-year follow-up. A prospective comparative cohort study was performed of 47 consecutive patients with ACL rupture included between May 2006 and March 2008. Inclusion criteria were less than 2 years since the injury date, no previous surgery on the affected knee, and having closed growth plates. Patients were divided into two groups: (1) SB group (n = 25) and (2) DB group (n = 22). Patients underwent evaluation before surgery and at 1 and 10 years postoperatively. The clinical evaluation included the International Knee Documentation Committee (IKDC) Questionnaire, pivot shift test, and single hop test, as well as X-rays (anterior drawer X-rays on a Telos stress radiography). Range of motion (ROM) was assessed at 10-year follow-up. Both groups were similar in terms of baseline characteristics. Post hoc power analysis showed that among 30 and 226 patients would be needed for statistical significance, depending on the outcome. With the numbers available, no significant differences were observed in subjective IKDC, anterior stability (measured with Telos), and functional test outcomes (single hop test) between both groups at 1 and 10 years postoperatively. Regarding rotational instability (pivot-shift test), DB group was significantly superior (p = 0.002). Regarding ROM, no significant differences were observed between groups. No failure was registered in any of the groups. ACL reconstruction (ACLR) with an autologous hamstring, both with bundles and DB, shows overall better outcomes compared with the status before surgery. DB ACLR provides better rotational control of the knee, an outcome that is maintained after 10 years.

Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction in Patients With Significant Passive Anterior Tibial Subluxation

BACKGROUND

Passive anterior tibial subluxation (PATS) is often observed in patients with anterior cruciate ligament tears. Postoperative outcomes of double-bundle (DB) and single-bundle (SB) anterior cruciate ligament reconstruction (ACLR) with significant PATS (>6 mm) are unclear.

HYPOTHESIS

DB-ACLR could achieve better stability and clinical outcomes than SB-ACLR in patients with PATS >6 mm.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Retrospective analysis was peformed on 626 consecutive patients who underwent primary anatomic ACLR between October 2016 and November 2017. Anterior subluxation of the lateral and medial compartments in extension relative to the femoral condyles was measured on preoperative magnetic resonance imaging scans. Among patients who demonstrated significant PATS (>6 mm) in the lateral compartment, 54 who underwent DB-ACLR (study group) were matched to 54 who underwent SB-ACLR (control group). PATS, stability (pivot-shift test and KT-2000 arthrometer), the Lysholm score, and the International Knee Documentation Committee (IKDC) grade were investigated preoperatively and at 3- to 4-year follow-up.

RESULTS

The preoperative mean PATS values in the lateral and medial compartments were not significantly different between groups (control vs study: lateral compartment, 8.1 ± 1.8 vs 8.5 ± 2.1 mm; medial compartment, 5.2 ± 1.9 vs 5.4 ± 1.9 mm; P > .05). Postoperatively, mean PATS values in the lateral and medial compartments of the study group were significantly improved as compared with the control group (control vs study: lateral compartment, 5.9 ± 2.8 vs 3.2 ± 4.1 mm; medial compartment, 3.7 ± 2.9 vs 1.4 ± 2.3 mm; P < .05). Significantly superior results were found for knee stability in the study group regarding the Lachman test (grade 0/1/2/3, study vs control: 29/22/3/0 vs 16/28/10/0; P = .031), pivot-shift test (grade 0/1/2/3, study vs control: 44/9/1/0 vs 30/19/5/0; P = .023), and KT-2000 arthrometer (study vs control: 2.5 ± 1.5 vs 3.9 ± 1.4 mm; P < .001). Clinical scores showed significantly better results in the study group in terms of IKDC score (study vs control: 87.9 ± 8.7 vs 81.2 ± 15.0; P = .01), Tegner activity score (study vs control: 6.0 ± 1.4 vs 4.9 ± 1.5; P < .001), and Lysholm score (study vs control: 91.7 ± 7.0 vs 86.3 ± 11.4; P = .004).

CONCLUSION

DB-ACLR achieved better knee stability and clinical outcomes when compared with SB-ACLR in patients with PATS >6 mm at 3- to 4-year follow-up.

Superior results of return to sport after double-bundle versus single-bundle anterior cruciate ligament reconstruction in young active patients

PURPOSE

To compare return to sport and clinical results in young active patients who underwent anatomic single-bundle (SB) versus double-bundle (DB) anterior cruciate ligament reconstruction (ACLR).

METHODS

Young active patients undergoing SB or DB ACLR from 2017 to 2019 at our institution were retrospectively reviewed. The primary outcome measures were the rate and time to return to sports, with secondary measures including the Lachman test, pivot shift test, Lysholm scores, International Knee Documentation Committee (IKDC) scores and graft rupture.

RESULTS

The study included a total of 90 patients (DB group, 42; SB group, 48), with a mean follow-up of 27.1 ± 6.1 months. Young active patients who underwent DB ACLR had a higher rate of return to pivoting sports than those who underwent SB ACLR (HR = 2.4; 95% confidence interval [CI]: 1.4, 4.1; p = 0.013). The DB group returned to pivoting sports at a mean ± SD of 11.0 ± 2.9 months compared with 12.7 ± 2.7 months in the SB group (p = 0.01). There was one traumatic failure in the SB group and one contralateral ACL rupture in the DB group. There was no significant difference in the rate and time to return to running, Lachman test, pivot-shift test, Lysholm or IKDC scores in either group.

CONCLUSION

Both anatomical SB and DB techniques achieved satisfactory clinical outcomes. DB techniques led to superior performance of return to pivoting sports but nonsignificant differences in time and rate of return to running, passive stability measurement, subjective knee function outcome and graft rupture rate in both groups at the 2-year follow-up. The DB ACLR should be considered a viable option to treat young patients with high activity demands.

LEVEL OF EVIDENCE

III.

Four-Tunnel Double-Bundle Anatomical Posterior Cruciate Ligament Reconstruction Without Remnant Preservation

Double-bundle posterior cruciate ligament (PCL) reconstruction has long been attempted to obtain better clinical results than single-bundle PCL reconstruction. In most previous reports regarding double-bundle PCL reconstruction, one tibial tunnel and various kinds of grafts were used. We introduce a two-tibial tunnel, double-bundle PCL reconstruction technique with ultra-strong grafts. The critical points of this technique are proper creation of the tibial tunnels and the protection of the posterior neurovascular structures. Our clinical experience indicates this technique can lead to satisfactory stable outcomes. We believe that this technique will provide a reasonable choice for PCL reconstruction without remnant preservation.

Reliable diagnosis of posterosuperior rotator cuff tears requires a combination of clinical tests

PURPOSE

Clinical diagnosis of posterosuperior rotator cuff tears remains uncertain due to a lack of evidence-based consensus. This review aimed to compare the diagnostic accuracy of commonly used clinical tests for posterosuperior rotator cuff tears.

METHODS

The authors conducted an electronic literature search using Medline, Embase and the Cochrane library/Central, to identify original clinical studies reporting diagnostic accuracy of clinical tests to diagnose the presence of posterosuperior rotator cuff tears involving the infraspinatus, supraspinatus and/or teres minor.

RESULTS

The electronic literature search returned 1981 records, of which 14 articles were eligible. Among 17 tests included in the systematic review, 6 tests were eligible for meta-analysis: drop arm sign, Jobe test, external rotation lag sign, Hawkins-Kennedy test, Neer test and painful arc abduction test. According to QUADAS-2 criteria, risk of bias was low in 1 study, moderate in 2 and high in 4. The highest pooled sensitivity was 0.77 (CI 0.67-0.85), for the Jobe test, while the lowest pooled sensitivity was 0.38 (CI 0.01-0.98), for the drop arm sign.

CONCLUSIONS

The Jobe test had the best pooled sensitivity, while the drop arm sign had the best pooled specificity. As no single clinical test is sufficiently reliable to diagnose posterosuperior rotator cuff tears, clinicians should consider various combinations of patient characteristics and clinical tests, as well as imaging modalities, to confirm diagnosis and select the appropriate treatment option. More reliable clinical diagnosis of posterosuperior rotator cuff tears could reduce the reliance on magnetic resonance imaging or arthrography and their associated costs and waiting times.

LEVEL OF EVIDENCE

Level II.